The AIDS Institute The Impact of the ACA and USPSTF Grade Change on Coverage of HIV Testing Lindsey Dawson Public Policy Associate United States Conference on AIDS New Orleans, LA September 9, 2013 The AIDS Institute Coverage of Preventive Services Under ACA • USPSTF and Grading • Coverage by each payer • Medicare • Private Insurance • Medicaid The AIDS Institute US Preventive Services Task Force (USPSTF) • Sponsored by Agency for Healthcare Research and Quality (AHRQ) at the HHS • Leading independent panel of private-sector experts in prevention and primary care • “Conducts rigorous, impartial assessments” of evidence for effectiveness of clinical preventive services, including screening, counseling, and preventive medications • Key to coverage determinations, particularly in health reform implementation The AIDS Institute USPSTF Grades Grade Definition Suggestions for Practice A USPSTF recommends the service. There is a high certainty that the net benefit is substantial. Offer or provide this service. B USPSTF recommends the service. There is a high certainty that the net benefit is moderate or there is a moderate certainty that the net benefit is moderate to substantial. Offer or provide this service. C USPSTF recommends against routinely providing the service. There may be considerations that support providing the service in an individual patient. There is at least moderate certainty that the net benefit is small. (Previously no recommendation for/against). Offer or provide this service only if other considerations support offering or providing the service to an individual patient. D USPSTF recommends against the service. There is no moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits. Discourage the use of this service. I USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined. The AIDS Institute Read the clinical considerations of the USPSTF Recommendation Statement. If the service is offered, patients should understand the uncertainty about the balance of benefits and harms. Statement USPSTF Grade A & B Recommendations (Partial List) • • • • • • • Alcohol misuse counseling Blood pressure screening Cervical cancer screening Chlamydial infection screening* Cholesterol abnormalities* Colorectal cancer screening* Depression screening • • • • • • • Gonorrhea screening* Healthy diet counseling* Hepatitis B & C screening* HIV Screening STI counseling* Syphilis screening* Tobacco counseling & screening * For “at risk” or certain sub-populations only (e.g. pregnant women, 50+) USPSTF & Routine HIV Screening • USPSTF revised its recommendation for routine HIV testing (April 2013) • Previously, the “A” grade applied only to those “at increased risk” for HIV and to pregnant women • “A” grade for those aged 15-65 • “A” grade for those “at increased risk” for HIV under age 15 and over age 65 • Reaffirmed “A” grade for pregnant women The AIDS Institute Health Reform • Health Coverage will be mandated • For most people, penalties for no coverage • Provides an estimated +34 million people with health care coverage • Medicaid Expansion (12m) • Health Insurance Marketplace/Exchanges (22m) • Private health insurance reforms • No pre-existing condition exclusion, no lifetime caps, checks on rate increases, non-discrimination policies • Increased coverage = more people with access to preventative care, including HIV testing The AIDS Institute Medicare and Health Reform • Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) • Medicare covers A & B preventive services after a coverage determination • As a result of the ACA, no cost sharing • Currently covers HIV screening at old grade, for pregnant women and those “at increased risk” • After a coverage determination, can cover routine • The Federal AIDS Policy Partnership's Testing Reimbursement Workgroup has requested that the Secretary to begin a new coverage determination The AIDS Institute Private Insurance and Health Reform • Under the ACA most plans required to cover A & B Services, without cost-sharing (Began September 2010) • Grandfathered plans exempt • Applies to plans inside and outside of the marketplace • Therefore, plans must currently cover “at risk” and pregnant women • Beginning the new plan year starting on or after April 30, 2014 (one year after the new USPSTF recommendation), plans will be required to cover routine HIV screening The AIDS Institute Private Insurance and Health Reform • Under ACA, non-grandfathered plans also required to cover a set of “Women’s Preventative Services” defined by the Secretary without cost-sharing. • Annual HIV screening and counseling for sexually active women one of eight preventive services identified by Secretary • Others include: • HPV screening • Counseling for sexually transmitted infections • Screening and counseling for interpersonal and domestic violence The AIDS Institute Private Insurance and Health Reform Non-grandfathered private individual and small group plans (inside and outside of exchanges) must 10 categories of Essential Health Benefits (EHB): • • • • • Ambulatory patient services Emergency services Hospitalization Maternity and newborn care Mental health and substance use disorder services, including behavioral health treatment • • • • • Prescription drugs Rehabilitative and habilitative services and devices Laboratory services Preventive and wellness services and chronic disease management Pediatric services, including oral and vision care “A” & “B” graded USPSTF services are also included through the preventative benefit category, as are other services The AIDS Institute Traditional Medicaid • Must cover medically necessary HIV testing under Social Security Act • State decision to cover routine testing • According to a Kaiser Family Foundation survey (as of Jan. 2013) • 30 states cover routine screening • 19 states cover “medically necessary” screening • 2 state did not respond The AIDS Institute The AIDS Institute Traditional Medicaid • ACA incentivizes states to cover USPSTF “A” & “B” services (incl. routine testing) • 1% increase in federal match for cost of covering all “A” & “B” and other preventive services • Began January 1, 2013 • States that fully align their Medicaid expansion package with traditional Medicaid will need to add these services The AIDS Institute Medicaid Expansion • ACA envisioned all states would expand their Medicaid programs to include those up to 138% FPL • Does away with categorical eligibility • SCOTUS decision effectively made expansion a state decision • Many states remain undecided or against but hope to see a phasing in of acceptance as with Medicaid and CHIP in the past The AIDS Institute State Decisions on Medicaid Expansion Source: Center on Budget and Policy Priorities. “Health Reform's Medicaid Expansion: A toolkit for State Advocates” http://www.cbpp.org/cms/index.cfm?fa=view&id=3819 The AIDS Institute Medicaid Expansion • Expanded Medicaid plans (Alternative Benchmark Plans) beginning January 1, 2014 • Required to cover all “A” and “B” grade services • Through the essential health benefits preventative service category • Services identified in Women’s Preventive Services package • Including annual HIV testing for sexually active women • No cost sharing The AIDS Institute Summary/Next Steps • ACA has improved access to reimbursable HIV testing and other preventive services across all payers • USPSTF grades are critical to coverage • Coverage varies by payer and state • State advocacy needed for Traditional Medicaid beneficiaries • Coverage determination need for Medicare • Availability of coverage does not automatically translate into usage • Need for education, outreach, and routinizing preventative care • Entities must develop tools for billing The AIDS Institute Summary/Next Steps • In a letter to the Secretary the HIV Testing Reimbursement Group recommended: • CMS issue a letter to state health officials: • Reviewing coverage changes occurring as result of grade change • Encouraging states to cover routine testing in traditional Medicaid • HRSA send a letter to grantees describing new recommendation and reimbursement potential • HHS undertake a review of avenues within the federal government where updates to HIV testing recommendations should be made and reimbursement urged (e.g. SAMHSA, VA, and other HRSA programs) The AIDS Institute Summary/Next Steps • CDC appropriated funding remains essential for HIV testing • Coverage is for those with health insurance • Reimbursement is for the actual test and counseling • Need to pay for outreach, staffing, linkage to care, partner notification services and reporting • HIV community will need to work with federal partners, private payers, and providers to increase testing and reimbursement practices • ACA opportunities and the USPSTF grade change will help make this possible but need to be operationalized on the ground The AIDS Institute Coverage of Preventative Services Under ACA The AIDS Institute The AIDS Institute Resources • USPSTF: http://www.ahrq.gov/clinic/uspstfix.htm • A & B services: http://www.uspreventiveservicestaskforce.org/uspstf/uspsabrecs.htm • HIV Screening: http://www.uspreventiveservicestaskforce.org/uspstf/uspshivi.htm • Kaiser Family Foundation Report on Medicaid coverage of HIV screening by state: http://www.kff.org/hivaids/upload/8286.pdf • Medicare Preventative Services: http://www.healthcare.gov/law/features/65older/medicare-preventive-services/index.html • The AIDS Institute’s HIV Testing Coverage Guide: http://bit.ly/178MNY4 • Healthcare.gov Prevention Section: https://www.healthcare.gov/prevention/ • Women’s Preventative Services: http://www.hrsa.gov/womensguidelines/ The AIDS Institute THE AIDS INSTITUTE THANK YOU To complete seminar evaluation: http://goo.gl/AKgwfd OR Lindsey Dawson ldawson@theaidsinstitute.org 202-835-8373 The AIDS Institute Appendix: Who is “At Risk?” Until implemented, current recommendation and risk based standards remain for some payers • A person is considered at increased risk for HIV infection (and thus should be offered HIV testing) if he or she reports 1 or more individual risk factors or • Receives health care in a high-prevalence or high-risk clinical setting More detail on clinical considerations for risk: http://www.uspreventiveservicestaskforce.org/uspstf05/hiv/hivrs.htm The AIDS Institute Appendix: Persons at Higher Risk for HIV Infection • Those seeking treatment for STDs • Men who have had sex with men • Past or present injection drug users • Persons who exchange sex for money or drugs, and their sex partners • Women and men whose past or present sex partners were HIV-infected, bisexual individuals, or injection drug users • Persons with a history of transfusion between 1978 and 1985 • Persons who themselves or whose sex partners have had more than one sex partner since their most recent HIV test • Persons who request a test The AIDS Institute Appendix: High Risk and Prevalence Settings • High-risk settings include STD clinics, correctional facilities, homeless shelters, tuberculosis clinics, clinics serving men who have sex with men, and adolescent health clinics with a high prevalence of STDs • High-prevalence settings are defined by the CDC as facilities known to have a 1% or greater prevalence of infection among patient population The AIDS Institute